《International Circulation》：According to the new updated ESH 2007 guideline ， what are the major differences between this version and the previous version? Are there any role changes of different drug classes like ARB， ACEI， CCB and beta blockers.

Prof. de Backer: Well， we are announcing them as an update. So these guidelines  are an  update of the   2003 guidelines; we are now 4 years later. In these 4 years， there have been a lot of publications， very good scientific publications， on better scientific knowledge on physiopathology， pathology， on the use of certain drugs， knowledge on life style changes. So the guidelines are  updated. In each of the chapters， starting with a definition up to the total risk estimation going over to the different clinical entities and different possible causes but  also in terms of management. In all these chapters， you’ll find the most recent publications we have used. The whole scientific knowledge being available until last weeks is in there. You have seen we have almost  eight hundred references so that the scientific background is huge and amazing. ?? You will find some differences， for instance， in total risk estimation， indeed， we are giving some new ideas in terms of management. I think that we have introduced all clinical trials that came out of last four years. So I cannot pinpoint one or another specific point， it is the over all picture that has been adapted according to the most recent scientific information that is available.

Prof. Laurent:  This is a short question for a very long answer. I侦l be very short because you ask me what are the differences between 2003 and 2007 guidelines. Very shortly， two types of differences. First the new diagnostic aspects now include three types of measurements: first， how to detect metabolic syndrome， to give importance to overweight， central obesity， fasting glucose. Second， how to detect arterial damage: measurement of arterial stiffness， measurement of ankle-brachial index. Third， how to detect more precisely kidney damage: instead of measuring creatinine， calculate and measure the glomerular filtration rate. These are the new diagnostic aspects. The second part is concerning the therapeutic aspects. The therapeutic aspect are considered as flexible. That means that the practitioner has the choice to choose the drug which he likes to prescribe according to certain recommendations， mainly according to the level of cardiovascular risk， and also according to target end-organ damage. For instance， select ACE inhibitors or ARB if there is left ventricular hypertrophy， please do not select b blockers if there is a metabolic syndrome or diabetes， etc.

Narkiewicz 教授：主要的不同是高血压的总体评估。我们有更多的危险因素去评价，比如对于早期肾功能损伤，建议每位患者都要评价肾小球滤过率；强调代谢功能异常的影响，这或许比代谢综合征更为棘手，它应作为心血管风险的高危因素；指南中第一次提出评价大动脉的功能十分重要，动脉壁厚度可作为心血管危险因素之一；靶器官的风险评价同样很重要，医生应该尝试评价靶器官功能，找出血管变化、心功能分级、血管分级，因为这些患者都存在多器官受损的情况。在治疗方面，有5大类药物可以选用，如ACEI、ARB及钙离子拮抗剂，另外还有利尿剂和β受体阻滞剂这类经典药物。指南中建议使用利尿剂及β受体阻滞剂时应该谨慎。

Prof. de Simone: In general， I think that the suggestions they give seem quite balanced， even better balanced than in the previous guidelines. There is still some difference from the American guidelines， in which the diuretics are the first treatment for virtually every hypertensive patient. But this is just an academic discussion. When you look at your patient to make your choice， you have a spectrum of various medications， very wide spectrum that you can use to improve your patient’s life. It’s enough. Guidelines do not prefer any type of drugs. There is some emphasis on the angiotensin receptor blockers. But you also know that the marketing is pushing this drug or medication with lots of trials. There is a strong evidence about the effect of angiotensin receptor blockers. We can’s avoid looking at these trials. What you may complain about is that we don’t have so many trials about diuretic， spironolactone， or other medications， even nitrates in the therapy of hypertension. There are no trials because there is no drug company really interested in sponsoring these trials. But the evidence is there， I mean， we can’s refuse the evidence. Trials like the LIFE study， a wonderful very well designed study， has produced something like 200 papers. It’s a very， very important study addressing the issue of the effectiveness of angiotensin receptor blockers. We can hope that some more evidence would come out with other medications.
Pro.Mancia: The new guidelines emphasize the concept of flexible target—flexible blood pressure target and also flexible blood pressure threshold. And this is based on evidence. There is evidence that you know for hypertensive patients， blood pressure target should be at least less than 140/90 mm Hg. But for high risk individuals， that are individuals with diabetes or history of cerebral vascular disease or history of coronary disease， blood pressure goals should be lower—less than 130/80 mm Hg. And in these patients， one should start treatment when they had blood pressure in the high normal range. So how to achieve this? It’s not easy at all. In many trials， the majority of patients did not succeed to going below 130 mm Hg. So we need more effective strategies and once again combination treatment is of utmost importance to try to hit target blood pressure in these individuals. 

《International Circulation》：It was reported by an article of Britain Medical Magazine in 2004 that angiotensin antagonists （ARBs） might increase the risk of Myocardial Infarction. From then on， the safety of ARBs has been received increasing attention. Do you think that ARBs may increase the risk of myocardial infarction? How to explain the possible mechanism ?
Prof. de Backer: The guidelines do not  recommend anything  based on just one  study. We are trying to oversee what we know today， and based on that knowledge，we are trying to give a good recommendation to the clinician and to the practitioner. And  on the particular issue of ARBs and myocardial infarction， I think at this moment， even when there are some studies suggesting something in one particular direction， the whole of the picture hold out the classic conclusion. We are recommending ARBs as one of the different options that we have in terms of different classes of hypertension control today， and  there is no reason to select out ARBs separately from other families that we have.

Prof. Laurent:  So this is exactly along what we have just said before. The only way for the moment is to pool all the studies， small and large， to get the largest number of patients， to get the highest statistic power. And if you do that， I’m also quoting the meta-analysis done by the BPLTC—blood pressure lowering Trialists Collaboration published in Journal of Hypertension at the beginning of this year. They showed very clearly that with ARB， the lower the systolic blood pressure， the lower the reduction in risk. So， among 100 percent， at least 90 percent of the job is done by lowering blood pressure. And ARBs are able to be used in coronary heart disease， fatal or notfatal. And remember the LIFE study: there was a clear reduction in coronary heart disease. Of course， compared to Atenolol， the difference was not significant because Ateno